a client who had an elective below the knee amputation reports pain in the foot that was amputated what is the best response by the nurse

ATI RN

Multi Dimensional Care | Final Exam

1. A client who had an elective below-the-knee amputation reports pain in the foot that was amputated. What is the best response by the nurse?

A. The pain will go away after the swelling decreases.
B. That is phantom limb pain.
C. Your foot has been amputated, so you are not having pain in that foot.
D. On a scale of 0-10, how would you rate your pain?

Correct answer: D

Rationale: The correct response is to assess the pain intensity by asking the client to rate their pain on a scale of 0-10. This helps the nurse to effectively manage the client's pain. Choice A is incorrect as it dismisses the client's pain without proper assessment. Choice B is incorrect as it assumes the pain is phantom limb pain without assessing the client's current condition. Choice C is incorrect as it invalidates the client's pain experience and does not address the issue at hand.

2. What complication of wound healing is an abnormal passage that connects two body cavities or a cavity and the skin?

A. Fistula
B. Hemorrhage
C. Evisceration
D. infection

Correct answer: A

Rationale:

3. The mother of a newborn baby is concerned that the baby will develop illnesses from being around people from outside of their family. What is the nurse's best response?

A. "You should never go around people after your baby is born,"?
B. "Why do you think that is a bad idea?"?
C. "Tell me more about that."?
D. "I did that, and my kids turned out just fine."?

Correct answer: C

Rationale:

4. What should be done immediately after an ankle injury?

A. Immobilize, heat, compress, and elevate the ankle
B. Rest, ice, compress, and lower the ankle
C. Rest, ice, compress, and elevate the ankle
D. Rest, incubate, confine, and lower the ankle

Correct answer: C

Rationale: The correct answer is C: Rest, ice, compress, and elevate the ankle. After an ankle injury, it is essential to follow the RICE method (Rest, Ice, Compression, Elevation) for immediate treatment. Resting the injured ankle helps prevent further damage, applying ice reduces swelling and pain, compression with a bandage provides support and helps control swelling, and elevating the ankle above heart level reduces swelling by allowing fluid to drain away from the injury site. Choices A, B, and D are incorrect because heating, incubating, or confining the ankle can worsen the injury by increasing swelling and inflammation instead of reducing them.